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CMOD Week 7 > Antimicrobials- Problems and Pitfalls > Flashcards

Antimicrobials- Problems and Pitfalls Flashcards

1
Q

Is Penicilin G narrow spectrum or broad?

A

narrow

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2
Q

Is Pen G penicillinase susceptible?

A

Yes

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3
Q

What are some common bugs Pen G is used against?

A

common Strep, meningococcal, G+ rods, spirochetes

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4
Q

What is the drug of choice for syphilis?

A

Pen G

Procain and benzithine are forms of Pen G administered IM (extended t1/2)

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5
Q

What is Pen V used for primarily?

A

oropharyngeal infections

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6
Q

Are Nafcillin and Oxacillin narrow spectrum or broad? Are they penicllinase susceptible?

A

Narrow; no

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7
Q

What are Nafcillin and Oxacillin commonly used for?

A

staphylococcal infections

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8
Q

Are Ampicillin and Amoxicillin narrow or broad spectrum? Penicillinase susceptible?

A

Broad; yes

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9
Q

What are some common bugs that Ampicillin and Amoxicillin are used for?

A

E. coli, Proteus mirabilis, H. influenzae, and Moraxella catarrhalis

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10
Q

T or F. The gastric acid environment of the stomach neutralizes penicillins

A

T, limiting their oral use

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11
Q

MOST penicillins are eliminated unchanged renally. Exceptions?

A

Nafcillin and ampicillin undergo hepatic elimination

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12
Q

Side effects of Penicillins?

A

All- allergic reactions
Ampicillin and amoxicillin- rash
Ampicillin, Amox, and Clav- diarrhea

All- hemolytic anemia
High dose piperacillin, ticaracillin or nafcillin- platelet dysfunction
(disrupts calcium)

Rare- Oxacillin, Ampicillin, Amoxcillin- hepatic damage, seizures and muscle irritability after high dose in renally impaired patients

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13
Q

Should Penicillins be taken with a full glass of water?

A

Yes

penicillins don’t effect CYPs at all

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14
Q

Do Penicillins have an effect on OCs? If so, what is it? If not, why?

A

Yes, they decrease the effectiveness of oral contraceptives (mechanism is via enterohepatic circulation).

Advise to take additional precautionary measures

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15
Q

What other antibiotic is a major inhibitor of OCs?

A

rifampin

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16
Q

What would Cefazolin (1st gen) be used to treat?

A

Staph, strep, E.coli, K. pneumoniae

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17
Q

Which 2nd generation cephalosporin is effective against H. influenzae?

A

Cefuroxime

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18
Q

Which 2nd generation cephalosporins are effective against Bacteriodes spp.?

A

Cefoxitin and cefotetan

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19
Q

Which bug are Cefotaxime, Ceftriaxone, and Ceftizoxime (3rd gen) particularly ineffective against?

A

Pseudomonas aeruginosa. Effective against other gram-

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20
Q

What are other cephalosporins that are more effective against Pseudomonas aeruginosa?

A

Ceftazidime (3rd gen) and Cefepime (4th gen)

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21
Q

How are most cephalosporins excreted?

A

renal. Thus, would need to alter dose if patient had kidney insufficiency

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22
Q

Which cephalosporin is not renally excreted?

A

Ceftriaxone- biliary excretion. Thus, no need to adjust dose for renal insufficiency

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23
Q

How are most cephalosporins given?

A

IV, some PO

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24
Q

Only a select few (4) reach CSF levels high enough to treat meningitis. Namely:

A

Ceftriaxone,
Cefotaxime
Ceftazidime
Cefepime

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25
Q

How should you advise a patient to take cephalosporins?

A

full treatment course should be taken. Take with food or milk to lessen GI distress

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26
Q

How should you advise patients taking cephalosporins regarding alcohol use?

A

Do not consume alcohol within 72 hr

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27
Q

Why shouldn’t a patient on cephalosporins drink alcohol?

A

they have been known to induce disulfram-like effect (especially with cefotetan)

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28
Q

What is a disulfram-like effect?

A

Acetaldehyde toxic effects are characterized by facial flushing, nausea, vomiting, tachycardia and hypotension, symptoms known as acetaldehyde syndrome, disulfiram-like reactions or antabuse effects.

Antabuse is given to alcoholics to induce these symptoms to stop them from drinking

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29
Q

What are some adverse effects of cephalosporins that should be reported immediately?

A

severe diarrhea, vomiting, skin rash, mouth sores, mouth swelling, breathing issues

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30
Q

What are some very frequent adverse effects of ALL cephalosporins?

A

1) thrombophlebitis with IV administration

2) Serum-sickness like reaction with prolonged parenteral administration

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31
Q

What is a very frequent adverse effect that of cephalosporins that is especially true of ceftixime?

A

moderate-severe diarrhea

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32
Q

What are some occasional adverse effects of cephalosporins?

A

1) hypersensitivity reaction

2) Pain at injection site

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33
Q

What are some occasional adverse effects of cefaclor (cephalosporins) in children?

A

rash and arthritis “serum sickness”

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34
Q

Other possible rare cephalosporin adverse effects?

A

hemolytic anemia, renal dysfunction, seizures, encephalopathy

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35
Q

What is a possible effect of long term cefazolin use?

A

bleeding dysfunction

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36
Q

Is Aztreonam beta-lactamase resistant?

A

Yes

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37
Q

What kinds of bugs is Aztreonam used for?

A

Klebsiella, pseudomonas, Serratia

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38
Q

What would Aztreonam never be used to treat?

A

gram positive bacteria or anaerobes- INEFFECTIVE

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39
Q

Are Carbapenems (Imipenem and Meropenem) susceptible to beta-lactamases?

A

low-susceptibility

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40
Q

What is Imipenem administered with?

A

Cilastin, a renal dehydropeptidase inhibitor

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41
Q

What are carbapenems commonly to treat?

A

gram +ve cocci, gram -ve rods and anaerobes

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42
Q

How Aztreonam administered?

A

IV/IM

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43
Q

How is Aztreonam excreted?

A

renal elimination with minor hepatic metabolic conversion

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44
Q

How are Carbapenems eliminated?

A

renal. Thus, dose adjustment for renal dysfunction necessary

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45
Q

How are Carbapenems administered?

A

IM/IV or IV (Meropenem)

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46
Q

What are some potential adverse effects of Aztreonam?

A

1) injection site reaction
2) GI pain
3) elevated ALT or AST
4) Rare- thrombocytopenia

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47
Q

What are some potential adverse effects of Carbapenems?

A

1) Injection site pain
2) fever
3) urticaria, rash, or pruritis (meorpenem)
4) GI disturbance

5) Rare- seizures (Meropenem MUCH LESS LIKELY to cause seizures compared to Imipenem), CDAD (C. diff associated disease)

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48
Q

How is vancyomycin given usually?

A

parenteral- well-distributed in tissue

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49
Q

When would vanco be given orally?

A

for C. diff infection

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50
Q

How is vanco eliminated?

A

unchanged in urine- thus, dose adjustment in renal failure necessary

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51
Q

What are some frequent adverse effects of vanco?

A

thrombophlebitis, fever, and chills

52
Q

What are some occasional adverse effects of vanco?

A

loss of hearing with large or prolonged dosing (more than 10 days)

renal damage

Red Man syndrome

53
Q

What are some rare adverse effects of vanco?

A

peripheral neuropathy, hypotension, exfoliative dermatitis, thrombocytopenia

54
Q

What is Fosfomycin used for? How does it work?

A

used primarily for uncomplicated UTI. It is given orally and eliminated via urine. In the urine it is effective enough to kill urinary pathogens (i.e. MIC is reached)

55
Q

What are some possible adverse effects of fosfomycin?

A

diarrhea and vaginitis

56
Q

What is daptomycin used to treat? How is it given?

A

gram+ infection (MRSA and vanco-resitant entercoccus faecalis/faecium); parenteral

57
Q

How is dapto eliminated?

A

renal.

58
Q

Side effects of dapto?

A

fever, headache, rash, injection site reaction

Rarely- elevated CPK and rhabdomyolysis, peripheral neuropathy, CDAD

59
Q

Dapto use should be monitored closely. Especially if the patient is taking ______.

A

HMG-CoA reductase inhibitors

60
Q

What are some common uses of tetracyclines?

A

chlamydiae, mycoplasma, rickettsiae spirochetes, H. pylori

61
Q

How is Tetracycline given?

A

PO

62
Q

How is Tigecycline given?

A

IV

63
Q

How are tetracyclines eliminated?

A

renal and hepatic

doxycycline- hepatic

64
Q

Is tissue distribution of tetracyclines good? What about CSF?

A

good penetration of tissues including CSF

65
Q

Side effects of tetracyclines?

A

1) GI distress (less for doxycycline)
2) severe renal damage with IV
3) tooth staining; photo-toxicity
4) RARE-Hairy tongue- bacterial or yeast outgrowth (common in heavy tobacco users, oxidizing mouthwashes)

66
Q

What side effect is especially common minocycline?

A

vomiting and vertigo (CNS effect)

67
Q

What are macrolides and ketolides commonly used to treat?

A

commonuity acquired pneumonia, pertussis, cornyebacteria, chamydia

renal and hepatic elimination

68
Q

What is clarithromycin inactive against?

A

gram- spp.

69
Q

What would telithromycin be used for?

A

mild-moderate community-acquired pneumonia ONLY

70
Q

How is clarithromycin given?

A

PO

71
Q

How is telithromycin given?

A

PO

72
Q

How are erythromycin and azithromycin given?

A

PO/IV

73
Q

Where are macrolides and ketolides commonly distributed to?

A

wide tissue distribution with accumulation in macrophages, spleen, liver, kidneys, and particularly the lungs

74
Q

Which macrolides/ketolides are CYP3A4 inhibitors?

A

erthyromycin and telithromycin,

and clarithromycin to a lesser extent

75
Q

How does azithromycin affect CYPs?

A

It does not

76
Q

What are SOME drugs you would want to monitor closely/adjust dosing if given concurrently with macrolides?

A

1) Midazolam with E or C
2) Clozapine
3) Theophylline
4) Warfarin

77
Q

Common adverse reactions to macrolides?

A

Reversible dose-related hearing loss, GI pain, increased hepatic enzymes, abnormal vision, injection site reactions

78
Q

How can macrolides affect the heart?

A

QT prolongation, Torsades de pointes

79
Q

Many experts advise against telithromycin use. Why?

A

can cause serious and fatal hepatotoxicity and cause serious visual disturbances

80
Q

What disease can telithromycin greatly exacerbate?

A

Myasthenia gravis

81
Q

How should tetracyclines be taken?

A

take full course, with full glass of water, no alcohol, avoid diary products (Milk)

**avoid sun or tanning lamps

82
Q

What would clindamycin be used for?

A

skin, soft tissue, and anaerobic infections outside CNS

83
Q

How is clindamycin administered?

A

PO/IV- good distribution with both

84
Q

How is clindamycin eliminated?

A

mostly hepatic with minimal renal excretion.

85
Q

Would you need to adjust clindamycin dose for renal dysfunction? Hepatic dysfunction?

A

Hepatic ONLY

86
Q

What are some possible side effects of clindamycin?

A

diarrhea, hypersensitivity

occasional CDAD

Rarely blood dyscrasia, hepatotoxicity, polyarthritis

87
Q

What is Chloramphenicol commonly used to treat?

A

H. influenza, Salmonella, CNS bacteriodes infections, vanco-resistant Enterococcus

good for pneumococcal or meningococcal meningitis

88
Q

How is Chloramphenicol given?

A

IV

89
Q

How is Chloramphenicol eliminated?

A

more than 90% are glucuronidated in the liver; and then fecal elimination

90
Q

In what group is Chloramphenicol especially dangerous in? Why?

A

neonates have immature hepatic function leading to drug accumulation (Grey Baby Syndrome- cyanosis, hypotension, and often death)

91
Q

How is Chloramphenicol distributed?

A

widely distributed; lowest levels in brain and CSF

92
Q

Side effects of Chloramphenicol?

A

black box warning- serious and fatal blood dyscrasia; some reports of aplastic anemia ending in leukemia

93
Q

What is Linezolid used to treat?

A

Enterococcus faecium and faecalis, including vanc. resistant

MRSA, Staph. epi and penicillin resistant Strep pneumoniae

given PO or IV

94
Q

How is Linezolid distributed?

A

widespread with great CSF penetration and good brain penetration

95
Q

Side effects of Linezolid?

A

reversible thrombocytopenia with prolonged administration, peripheral and optic (nerve) neuropathy (loss of vision), serotonin syndrome with pts taking SSRIs (selective serotonin re-uptake inhibitors)

96
Q

How do aminoglycosides work?

A

block formation of translation initiation complex, causing mis-reading

work in an oxygen-dependent manner

97
Q

Are aminoglycosides effective against gram positive bugs?

A

No, gram- only. Synergistic with beta-lactams

98
Q

What is Amikacin (aminoglycoside)

used for?

A

generally reserved for bacteria known or suspected of being resistant to the other aminoglycosides

99
Q

What is Genatmicin (aminoglycoside) used for?

A

hospital-acquired infections; H. influenzae, M. catarrhalis, Shigella

100
Q

What is Tobramycin used for?

A

similar to gentamicin;

In vitro studies suggest higher activity vs. P. aeruginosa & lower activity vs. Serratia

101
Q

How are amingoglycosides administered?

A

parenteral (neomycin cant because of toxicity)

102
Q

How are aminoglycosides eliminated?

A

100%- renal function is critical here

103
Q

Side effects of aminoglycosides?

A
  • BLACK BOX WARNING:**
    1) neuro and ototoxicity (ear)- avoid with concurrent neurotoxic agents
    2) nephrotoxicity– avoid with concurrent nephrotoxic agents
    3) Neuromuscular blockade- respiratory paralysis possible

agranulocytosis, anaphylactoid reactions, dermal reactions

104
Q

What do you need to monitor when giving aminoglycosides?

A

BUN/Cr, serum drug levels, audiometry

105
Q

What is clotrimoxazole given for?

A

urinary tract infections, shigellosis, otitis media, traveller’s diarrhea, bronchitis, Pneumocystis jiroveci pneumonia, Nocardia, MRSA infections

106
Q

How is clotrimoxazole given?

A

PO, or IV for serious infection

107
Q

How is clotrimoxazole eliminated?

A

equal hepatic and renal. Dose adjustment for both dysfunction

108
Q

Side effects of clotrimoxazole?

A

Allergic reactions are common esp. with HIV

Occasional: elevated SCr, hyperkalemia ; renal insufficiency

109
Q

What are the fluoroquinolones?

A

ciprofloxacin, ofloxacin, levofloxacin, Gemifloxacin, Moxifloxacin

110
Q

How is cipro eliminated?

A

hepatic and renal with significant CYP metabolism

• Inhibit CYP1A2, 3A4

111
Q

How is olfoxacin eliminated?

A

mostly renal and uncharged

112
Q

How is levofloxacin eliminated?

A

mostly renal and uncharged

113
Q

How is gemifloxacin eliminated?

A

eliminated largely unchanged; stool over urine

114
Q

How is moxifloxaxin eliminated?

A

eliminated largely as parental conjugates in stool and urine

115
Q

Which fluoroquinolones require dose adjustment in renal dysfunction?

A

All but moxifloxacin

116
Q

Side effects of fluoroquinolones?

A

BLACK BOX* tendonitis and tendon rupture risk in all ages, especially in elderly, patients on corticosteroids and pts with heart/lung/kidney transplant

may exacerbate weakness in pts with myasthenia gravis

117
Q

Rare side effects of fluoroquinolones?

A

cardiovascular toxicity, arrythmias, and QT prolongation

acute renal failure

Dermatologic rashes, Stevens-Johnson syndrome and photosensitivity

118
Q

What event can cause increased accessibility to the CSF via inhibited P-gp activity?

A

inflammation of meninges

Also there is less CSF production to block drug access and the inflammed meninges are leakier

119
Q

Which antimicrobials should not be given during pregnancy?

A

clarithromycin, tetracyclines, and sulfonamides (Clotrimoxazole)

120
Q

How are quinupristin-dalfopristin administered?

A

IV

121
Q

How are quinupristin-dalfopristin eliminated?

A

mostly heptic with minimal renal

122
Q

Is quinupristin-dalfopristin disrtibution good?

A

yes

123
Q

Drug interactions with quinupristin-dalfopristin?

A

strong CYP3A4 inhibitor

124
Q

Side effects of quinupristin-dalfopristin?

A

frequent thrombophlebitis, arthralgia, myalgia

not common b/c of use of linezolid or dapto

125
Q

The post-antibiotic effect states that continued inhibition of microbial expansion/activity after serum drug level falls. How?

A

1) slow recovery after reversible nonlethal damage to cell structures
2) persistence of the drug at a binding site or within the periplasmic space
3) the need to synthesize new enzymes before growth can resume
4) postantibiotic leukocyte enhancement (PALE)

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